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ApplicationsWill Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. FOR OFFICE USE- APPLICATION (For Non-Transferable, Revocable, Suspendable) 1 " ENVIRONMENTAL HEALTH PERMIT PUMP&WELL (COMPLETE IN TRIPLICATE) WATER QUALITY 6 T— .5 Application is hereby made to the San Joaquin LOCa'I,HeMtfl District fora permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No. 1862 and the rules and regulations of the San Joaquin Local Health District. Exact Site Address 15850 RANCHO RAMON City/Town TRACY t � � Owner's Name J.D. MOST CONSTRUCTION Phone 835-6921 Address 49 E. 10th ST. City TRACY Contractor's Name FREITAS ELECTRIC License# 338471 Business Phone 835-281 4 Contractor's Address 53 W. nG11 ST. Emergency Phone S A Is Certificate of Workman's Compensation Insurance on t=ile With SJLHD? Yes X No I TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ k WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION I31 PUMP REPAIR I REPLACEMENTO `S DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy - Sewage Disposal Field Cesspool/Seepage Pit Other Property Line Private Domestic Well Public.Domestic Well INTENDED USE TYPE OF WELL ❑ INDUSTRIAL -O-C"ABLE-T—G - ._ isi�of�U41eI Ecav xation t DOMESTIC/PRIVATE DRILLED Dia. of Well Casing 1 ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal Vi ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout ❑ DISPOSAL ❑ OTHER Other Information �} ❑ GEOPHYSICAL Surface Seat Installed By: PUMP INSTALLATION: Contractor FREITAS ELECTRIC Type of Pump SUBMERSIBLE I HF. 1- t PUMP REPLACEMENT: ❑ State Work Done ; PUMP REPAIR: ❑ State Work Done `1► DESTRUCTION OF WELL: Well Diameter Approx ate Depth Describe Material and Procedure 'S I hereby certify that I have prepared this application and that the work will be done in acct rda�ce with San Joaquin County , ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following:"I certify that'in the performa ce of the work for which this permit is issued, I shall not employ any, o_ person in such manner as tbecome,subject to workman' compensation laws of California." Contractor's hiring or sub-contracting signature certifies th_elollow`ing:"I certify that in the performance of the work forwhich this permit is issued, I shatikemployypersgns_subject�to-.workman's compensation laws of Califotnia." I WIIP for rout Inspe`fibn prior to grout g and a final inspection.-- -K Signed �` J Title: x ` - Date: (Draw Plot Plan on Reverse Side) FOR PARTME7 USE ONLY t� PHASE - Application Accepted By. Date Additional Comments: i Phase II Grout Inspection C P se III Final Inspection,, r, Inspection By Date Inspection By Date T Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January I &Received By January 31 ❑ Jury 1 &Received By July 31- BILLING REMITTANCE $ REMIT BASE EXPLANA ION PATE - DATE REMITTED AMOUNT DUE CHECKED - AMOUNT FEE LESS PRORATION 'i PLUS PENALTY I - OTHER r1 OTHER 3'17 94st -7q i Received by Date Receipt No Permit No. Issuance Date Mailed De4ivered i �� r i APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL REALERMIT7SERVICES 1661 E.HAZELTON AVE.,P.O.Box 2009 STOCKTON,CA 95201 �,.'